Center for Studying Health System Change

1 in 4 Primary Care Doctors Concerned About Care Expected to Provide Without Referral to Specialists

News Releases
December 22, 1999

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ASHINGTON, D.C. -- The Center for Studying Health System Change (HSC) today released a new study (see HSC Issue Brief #24 "The Scope of Care Expected of Primary Care Physicians: Is it Greater than it Should Be?") showing that 24 percent of primary care physicians (PCPs) report concern about the care they are expected to provide to sicker patients without referring them to specialists. The study, published in the December 23rd issue of the New England Journal of Medicine, also indicates that 30 percent of PCPs report that their so called "scope of care" - the complexity or severity of patients’ conditions for which PCPs provide care without referring to a specialist - has recently increased.

The HSC study finds that PCPs who serve as "gatekeepers" for their patients and work under capitation arrangements that put them at financial risk for care delivery, are more likely to be concerned about the scope of care expected of them. PCPs’ concern is particularly evident among PCPs who report an increase in their scope of care, as well as those who practice in smaller size groups or in certain specialties. These findings are adjusted for a number of factors that could affect the results.

"Whether the concern expressed by PCPs is the result of techniques managed care plans have put in place to control access to specialists, because of advances in diagnostic and treatment options, or some other factors, the findings merit attention from public and private decision makers," said Robert F. St. Peter, M.D., HSC senior medical researcher and principal author of the study. "Possible responses to this study include more intensive efforts to monitor quality of care, particularly appropriate access to specialty services, as well as enhanced training and ongoing education of physicians."

In this same study, 50 percent of specialists report that the scope of care provided by PCPs has increased. Further, 38 percent of specialists said that the complexity or severity of patients’ conditions at the time of PCP referral was greater than it should be.

"There has long been an interest in enhancing the role of primary care physicians as a way of coordinating and providing more cost effective care, particularly given the greater reliance on specialists in the U.S. compared with other countries," said Peter Kemper, Ph.D., principal investigator of HSC’s Community Tracking Study and a co-author of the study. "This study provides physicians’ perspective on whether PCPs current scope of care is appropriate."

Factors related to PCPs’ concerns about expected scope of care include the following: (For more complete figures, see HSC’s Issue Brief #24 "The Scope of Care Expected of Primary Care Physicians: Is it Greater than it Should Be?".)

• As many as 28 percent of PCPs who serve as gatekeepers expressed concern about scope of care, compared with 16 percent who do not have any patients for whom they serve as a gatekeeper;
  
  
• As many as 26 percent of those who are capitated report concern about scope of care, compared to 20 percent for those who derive no income from capitation;
  
  
• 27 percent of those who practice in solo or two physician practices (about 40 percent of all physicians) report concern about scope of care, compared to 16 percent for those who practice in a group of more than 50 physicians; and
  
  
• 26 percent of internists are concerned about scope of care, compared to 22 percent of family physicians.

"Physicians who practice in larger groups have access to ’curbside consults,’ a range of formal and informal interactions with their colleagues - which may help mitigate concerns about expanded scope," said Roger Taylor, M.D., senior strategist at RAND and former chief medical officer of PacifiCare Health Systems Inc. "The fact that three-fourths of PCPs report that today’s scope of care is about right, and physicians with broader training and more years of experience were more comfortable than others, suggest that time, experience and ongoing education may ultimately resolve this concern."

The results in this study are from HSC’s bi-annual nationally representative physician survey, which was fielded between July 1996 and July 1997, and includes more than 12,000 physicians. The survey provides physician insight into how care delivery is changing, but does not directly provide information about clinical quality.

The Center for Studying Health System Change - an independent research organization funded exclusively by The Robert Wood Johnson Foundation - provides objective, timely analyses about changes in the nation’s health care system and their impact on consumers to private and public decision makers. HSC, based in Washington, D.C., is affiliated with Mathematica Policy Research, Inc.